Your mammogram may not be fully covered by insurance primarily due to the type of mammogram performed. Insurance plans generally distinguish between a screening mammogram and a diagnostic mammogram, and their coverage rules differ significantly.
Screening vs. Diagnostic Mammograms: The Key Difference
The main reason for a mammogram not being fully covered often lies in whether it was performed for routine preventive care or to investigate a specific health concern.
| Feature | Screening Mammogram | Diagnostic Mammogram |
|---|---|---|
| Purpose | A routine check-up for individuals without any breast symptoms or concerns. It's used for early detection of potential issues. | Performed when you have a specific breast symptom (like a lump, pain, nipple discharge) or when a screening mammogram shows an abnormal finding that needs further investigation. It's used to diagnose something specific. |
| Coverage | Generally covered 100% by most insurance plans as preventive care, meaning you typically don't pay a copay, coinsurance, or deductible. | Since it's used to diagnose an existing issue, it's treated more like a medical service. You may be responsible for a copay, coinsurance, or need to meet your deductible before your insurance begins to pay, depending on your specific plan. Most preventive cancer screenings are covered, but diagnostic services are handled differently. |
| Frequency | Typically recommended annually or biennially, based on age, risk factors, and professional guidelines. | Performed as needed, based on medical necessity, to follow up on a symptom or abnormal finding. |
Most preventive cancer screenings, including screening mammograms, are mandated to be covered by insurance with no out-of-pocket costs, thanks to provisions under the Affordable Care Act (ACA). However, a diagnostic mammogram falls into a different category.
Common Reasons for Non-Coverage or Out-of-Pocket Costs
If your mammogram wasn't fully covered, beyond being a diagnostic procedure, here are other common reasons:
- Deductible Not Met: For diagnostic services, your insurance plan may require you to pay a certain amount (your deductible) out-of-pocket each year before your insurance starts covering costs.
- Copay or Coinsurance: Even after meeting your deductible, you might still owe a fixed copay amount or a percentage of the service cost (coinsurance) for diagnostic services.
- Out-of-Network Provider: If you received the mammogram at a facility or from a doctor who is not part of your insurance plan's network, your coverage might be reduced, or the service might not be covered at all.
- Lack of Pre-authorization: Some diagnostic procedures, especially if complex or expensive, may require prior authorization from your insurance company. If this wasn't obtained, the claim could be denied.
- Billing Error: Sometimes, the facility might have accidentally used the wrong billing code, leading your insurer to process it as a different type of service or deny it.
What to Do If Your Mammogram Isn't Covered
If you've received a bill or an Explanation of Benefits (EOB) showing your mammogram wasn't fully covered, follow these steps:
- Review Your Explanation of Benefits (EOB): This document from your insurance company will detail what was covered, what was denied, and often, the reason for the denial or the amount you owe.
- Contact Your Insurance Provider: Call the member services number on your insurance card. Ask for a clear explanation of why the claim was processed the way it was. Inquire about the billing code used and how it impacted coverage.
- Communicate with the Facility's Billing Department: Ask the facility where you had the mammogram what CPT (Current Procedural Terminology) code they submitted to your insurance. Knowing if it was billed as a screening (e.g., 77067) or diagnostic (e.g., 77065, 77066) can clarify the situation.
- Discuss with Your Doctor: If you believe the mammogram should have been covered as a screening, or if it was diagnostic but there's a billing discrepancy, your doctor's office can sometimes help by providing additional medical necessity documentation or verifying the type of mammogram ordered.
- Appeal the Decision: If you believe your insurer made an error, you have the right to appeal their decision. Your EOB will typically provide instructions on how to start the appeal process.
Preventive Care and Your Rights
It's important to remember that the Affordable Care Act mandates that most health plans must cover a range of preventive services, including screening mammograms for women within certain age groups and risk profiles, without requiring you to pay a copayment, coinsurance, or deductible. Understanding whether your mammogram was for screening or diagnosis is key to understanding your coverage.
For more information on preventive services covered by insurance, you can visit Healthcare.gov's section on Preventive Services.
